Antimicrobial resistance – Are we losing the battle against bacteria?

By Dr Claire Thompson, RPS Deputy Chief Scientist

Meeting with world health officials in October, Prof Dame Sally Davies, England’s Chief Medical Officer, repeated her warning that if antibiotics lose their effectiveness it would spell the end of modern medicine.

It has been 18 months since Jim O’Neill made his final recommendations on how we can tackle antimicrobial resistance (AMR) globally.  These included the need to:

– Increase public awareness of AMR;
– Reduce the over/inappropriate use of antibiotics;
– Prevent the spread of infections;
– Increase research into new antibiotics by generating a $2bn Global Innovation Fund.

Since then, little has changed within the UK.

At the BioInfect 2017 event Jo Pisani, Pharma & Life Sciences Partner at PwC, gave her state of the nation address on antibiotics and was disappointed to see that little has changed in the pipeline of new antibiotics since the O’Neill reports. “The UK has opportunity to be world leader in antibiotic development, but with so few companies involved in antibiotic R&D, how do we advance the pipelines?” she said.

Source: Antimicrobial resistance: The state of the nation report on UK R&D. PwC. https://www.pwc.co.uk/industries/healthcare/insights/antimicrobial-resistance.html

Where are the new antibiotics?

At the moment, there are less than 100 scientists in the Pharma Industry who are working on new antibiotics. This is mainly due to the lack of reimbursement models for antibiotics.

There have been calls for new models and incentives for developing antibiotics, such as exclusivities on market entry akin to those which are in place for orphan drugs or paediatric medicines, but these are yet to come to fruition.

This means that organisations such as the AMR Centre, charities such as Antibiotics Research, and small companies like Auspherix are leading the charge in developing new antibiotic medicines.
In order to progress the development of new antibiotics, we need to stop focussing on what they are going to cost and start thinking of cost of not having them.

What are we doing to combat AMR?

The key to overcoming AMR is not just about new antibiotics; improving stewardship and raising awareness are imperative. As a profession, these are some of the activities we are involved in.

Public engagement and awareness
With 1.6 million pharmacy visits per day, pharmacists are perfectly positioned to talk with patients and the public about what antimicrobial resistance is, when antibiotics are required, and how to take them. The Test and Treat service at pharmacies is under-utilised. Currently, people aren’t aware of it and don’t know they can talk to their pharmacist.

Antimicrobial Stewardship Programme
In September, the RPS launched the Antimicrobial Stewardship programme  which contains reference, guidelines and support tools for pharmacists.

What impact can we have?

In 2016, Government set a challenge of reducing inappropriate antibiotic prescribing by 50% by 2020. Pharmacists are integral to this. As a profession, we still have some work to do to ensure that the public know that they can talk to pharmacists about health concerns and to get advice on medicines. But the impact we can have as pharmacists (on raising awareness and providing stewardship) and as pharmaceutical scientists (in developing new antibiotics) is enormous.

A tweet from the BioInfect 2017 summarised this perfectly “Great way to cut queues at your GP. Talk to your pharmacist and conserve our antibiotics”.

Contrary to the saying, resistance is not futile – it is rife. But the war on bacteria is not over! Please play your part.

Mother was right!

“Wash your hands when you come in”, “Make sure you wash before dinner”, “Show me your hands” – just some of the echos of my childhood which I’m sure many of you recognise.
Ahead of World Antibiotic Awareness Week  and European Antibiotic Awareness Day  I spent much of my time at the RPS researching, collating and checking resources to support antimicrobial stewardship for the RPS AMS Portal.
I learnt a lot and guess what – our mothers were right!  One of the simplest ways to reduce the use of antimicrobials is hand washing (or hand hygiene as it is referred to in healthcare settings).  Not just to remove visible dirt but to remove bacteria and viruses which could cause infections such as upset stomachs, coughs, colds or pneumonia. Washing your hands properly should take 20 seconds, as long as it takes to sing “Happy Birthday to you” twice.
Simple you think – but wait – the RPS Handwashing essential guide states that 84% of British adults don’t wash their hands for long enough and 65% of people don’t always wash their hands before eating. The infographic below has other figures which make uncomfortable reading.

I mentioned these gruesome figures one evening at home and an unexpected consequence was that my daughter, who teaches a Year 2 class, was interested in using this information at school in some way.  I suggested having a look at the e-bug resource (another resource found during my AMS research) and together with the ‘handwashing and mouldy bread experiment’ (look it up on youtube!) she formulated a lesson plan.  The children loved it – and it became a feature of their end of term assembly.
So, what started as a literature review style research project on antimicrobial stewardship and resistance ended up as a theme for a school assembly.  It illustrates that antimicrobial stewardship belongs to us all – organisations, health professionals and all ages of members of the public.  Now, during World Antibiotic Awareness Week, take some time to have a look at the AMS Portal.  This is essentially a signposting resource linking to antimicrobial stewardship resources under six key categories: strategy, policy and guidance; clinical and technical guidance, initiatives and campaigns, training and educations resources, journals; and organisations.  The AMS Portal focuses on GB resources for pharmacists and pharmacy teams although we recognise the need to signpost to worldwide information and resources from outside GB are also included.
Have a browse – you might even find yourself influencing another school lesson or even humming ‘Happy Birthday to you, Happy Birthday to you………………….’!

Grant application success!

Kristina Medlinskiene, previous course attendee

Writing a grant application for the first time is not easy to say the least (or maybe it never gets easy). I recall my very early start on this endeavour with very rough knowledge of what it may entail. The RPS two-day research proposal workshop gave me clarity but it also raised many more questions about issues I hadn’t even thought about!

Patient public involvement group? Advisory group? Before the workshop I had not thought about forming these groups or had any idea how to do it. Methodology? Theoretical framework? Detailed costs of the project? Just a few things that I needed to find answers to.

The format of the two days stimulated thinking about your project and the grant application. Most importantly it gave me a direction, a sense of ‘right, this is clearer now’. By the end of the two days I had a preliminary action plan with identified crucial tasks that I needed to address first.

The two days consisted of presentations and workshops covering various topics from how to build a case for the funding application, to the data processing and analysis. Whilst some topics were covered briefly, I read more about it in the book provided and referred back to it for some quick pointers.

Personally, the biggest benefit of attending the two-day workshop alongside the workshops was networking. You not only get a chance to meet and hear experiences of pharmacists who have gone through the process but also ask them for advice later when you are writing your application and get stuck! They were incredibly helpful.

As I have learnt writing a grant application requires a lot of commitment, persistence and some sleepless nights. Get all the help you can, even if it means pushing barriers of your confidence!

If you don’t know how to start writing an application, these workshops could be what you need. They helped me with my application writing.

The RPS will be running a research proposal writing workshop on the 6-7th March 2018. See our events page for more information and to book your place. This course has very limited numbers so please don’t hesitate and secure yours now. We want to ensure you get the grant funding you deserve by writing a successful grant application.

Community pharmacy: a gateway to health

by  Gill Hawksworth MBE, FRPharmsS and RPS Faculty Fellow

I have been trying to keep track of a gradual change in attitudes about pharmacy and public health and now,18 months on from when the Murray Review was commissioned, find myself asking ‘What does it all mean?’.

In September 2017, several key announcements began with the new Pharmacy Minister Steve Brine who said at the RPS conference that initiatives such as the work of (HLP) and flu vaccination services highlight pharmacy’s role in promoting public health and reducing health inequalities. Also at the Labour party conference, the Pharmacy APPG Chair  and Labour MP for Rother Valley, Kevin Barron, said they would like to see the HLP initiative included in the community pharmacy contract as it has a ‘role to play in improving public health’. This was encouraging, so the message must be getting through somehow to those who could influence change and this is backed up by the news that the Public Health England (PHE) report ‘Pharmacy: A Way Forward for Public Health’ has been published.

This new report sets out opportunities for commissioners, some of whom have previously decommissioned such services, to realise community pharmacy’s role in protecting and improving the nation’s health, flagging up growth in the HLP programmes since a quality payment is now available for attaining HLP1 status. The CPPE are supporting this with leadership for HLP workshops and the paper also looks at developing capacity in the workforce to support promoting health through pharmacy settings and lists smoking cessation among the menu of opportunities for community pharmacists to get involved, timely for the PHE Stoptober challenge.

PHE is working with the Pharmacy and Public Health Forum to collect case studies of promising practice to help identify opportunities to build on current learning and scale what is working and has been shown to have impact.  Interestingly there is already a move in Scotland (the vision of Achieving Excellence in Pharmaceutical Care) to expand the public health role with evidenced-based interventions, so pharmacy is at the heart of delivering national health and well-being priorities.

A further focus in September was on support for the role of community pharmacists in antimicrobial stewardship, highlighted in the RPS national campaign, and again during World Antibiotic Awareness Week this week.

There was also an article by Professor David Wright (who’s literature review informed the Murray Review) on the potential for revised Medicines Use Reviews (MURs). We must remember that a range of public health interventions are often part of an MUR. This can include looking after the mental health and wellbeing, as well as physical health, of elderly patients who may be lonely, supported by CPPE’s work on mental health. This also offers a chance for pharmacists to fulfil other roles such as in cancer awareness and screening referral.

Making every contact count and documenting public health interventions may be a good place to start and help to develop the evidence base, remembering that the Murray Review stated ‘we should note that the evidence for (or against) specific clinical services within the peer-reviewed literature is often relatively sparse’.

All this is developing within the context of RPS working with PHE and NHS England to promote the role of pharmacists in public health, with the support of the RPS Professional Standards for Public Health Practice for Pharmacy.

So as attitudes are gradually changing and funding of public health services are being considered in terms of the evidence available, I await, with interest, the public consultation I understand is coming soon on the work by NICE on community pharmacy public health interventions. This deals with the evidence, (RCTs as gold standard) therefore relying on documentation of public health interventions such as alcohol, sexual health and of course smoking. After all, community pharmacists I believe have a good track record in helping people stop smoking.